Originally published in ASCO Daily News
“Poor Niagara,” Eleanor Roosevelt reportedly murmured when she first saw the mighty Iguazu Falls. Standing twice as tall and three times wider than its famous counterpart at the U.S. and Canadian border, these falls are a wonder of the natural world that words can barely do justice to describe. The South American cataracts are a feast to all senses. They are visually stunning: the brown water seemingly turns black as it flows over the granitic rock, then white and silver as it plummets, framed by all shades of green from the surrounding tropical forest that comprises most of the Iguazu National Park on both sides of the Argentinian–Brazilian border. As the immense mass of fast-flowing water violently hits the ground underneath, it generates a perpetual cloudy mist and a deafening roar, adding to a dream-like atmosphere that marvels visitors from all over the globe.
After the falls, the lower Iguazu River meanders slowly for another 12 miles or so until it joins the Paraná, the second largest river in South America, which continues south for a thousand miles before it merges with the Paraguay and Uruguay rivers to create the River Plate. This fluvial system not only is the source of names for many countries (and soccer teams) in the region, but it also harbors one of largest biodiverse areas in the world and the largest hydroelectric dam outside of China.
In the city of Foz do Iguaçu (which literally means Iguazu River Mouth) on the Brazilian side of this three-country border (it is here that Brazil, Argentina, and Paraguay intersect) my colleagues and I met to launch our updated review on the state of cancer control in Latin America and the Caribbean. Our updated findings, published in The Lancet Oncology in 2013 and led by Paul Goss, MD, PhD, showed several shortcomings when we compared the landscape in the region with that of higher-income countries.1 We showed that countries in Latin America and the Caribbean spend significantly less than their richer counterparts in both absolute and relative terms and that there were also disparities within the region and within countries. We also reported a scarcity of adequate cancer registries, hampering the design of credible and successful cancer control plans, including efforts at primary disease prevention.
When asked to write an update barely a couple of years after the original report, many of my coauthors and I were skeptical that we would see any change. We were very glad to show many improvements, however, and these improvements were illustrated during the Brazilian Society of Clinical Oncology Annual Meeting and in a concomitantly published article in The Lancet Oncology.2 There have been structural reforms in health care systems, better training of cancer professionals, new initiatives for populations at high risk, expansion of cancer registries and cancer plans, and implementation of policies to improve primary prevention, early diagnosis, and treatment.
Incrementing Financial Resources for Cancer Control
Countries in Latin America and the Caribbean are spending more on health care as a percentage of gross national product, and, with that, access to high-cost drugs and procedures have increased. However, expenditures are still much lower than in high-income countries, and funding of expensive cancer drugs in public health systems is still scarce, which has resulted in patients’ increased use of the legal system and courts to gain access to newer medications. The constitutions in Brazil and Colombia, for instance, make it a responsibility of government to guarantee access to health care, including cancer medications. There are approximately 240,000 health-related lawsuits at several levels in the Brazilian judiciary today. During the 2015 ASCO Annual Meeting, my colleagues and I published an abstract showing that 3.56% of patients in Brazil obtained their medications through lawsuits, and that this number increased by 65.5% over a 2-year period. Drugs most commonly obtained through court orders were trastuzumab, sunitinib, erlotinib, capecitabine, and abiraterone.3
Restructuring of Health Care Systems
The proportion of people covered by at least basic health insurance in the region has increased from 46% to 60% between 2008 and 2013.1Actions to protect uninsured patients against catastrophic health expenses have been implemented in some countries, such as Mexico and Uruguay, but most nations still have highly fragmented health care systems with persistent inequalities and segregation of health care. Only Brazil, Cuba, and Costa Rica can be considered to have true universal health care, but even in these countries there are disparities across states (and provinces) and between urban and rural settings.
Optimizing the Oncology Workforce and Technology to Meet Regional Needs
Awareness of the shortage of cancer specialists and the number of oncologists in Latin America has steadily increased, most notably in Brazil and Argentina, where the numbers of new professionals has risen quickly. In a few countries, such as in Guatemala and Mexico, patient navigators now help overcome cultural and logistical barriers for indigenous and rural patients with cancer.
The number of cancer cases per oncologist, however, is still much higher than in higher-income regions, and the availability of palliative care services and physicians is still very low and inadequate.
Despite initiatives to address the concentration of professionals and services, most cancer specialists and centers in Latin America are still in large, tertiary cancer centers in urban settings. Innovative strategies, including use of telemedicine, retraining of specialists, and incentive systems are gaining ground but have yet to be widely implemented.
The under-implementation of new technologies has not improved substantially since the original report. Insufficient quality of histopathological assessment is still a concern, as exemplified by the poor quality of Pap smears shown in cervical cancer screening studies. Long wait times are still a major issue, impairing the effectiveness of screening, prevention, and early detection actions.
Investments Relevant to the Region
The region has taken important initial steps to improve registry data: there was an increase of 40% in cancer registries between 2011 and 2014, but population coverage of these registries is still low.1 Moreover, although many ambitious new cancer control plans and policies have been undertaken, full implementation is still awaited. Community-based participatory research, which addresses specific barriers and interventions that must be overcome, is a promising new area of regional research in Latin America.
Unfortunately, despite some improvement, long-term outcomes of cancer control initiatives are not always adequately monitored or reported, and preclinical and clinical research in oncology originating in Latin America have not increased substantially.
Countries in Latin America and the Caribbean have, however, made many new postgraduate educational and training initiatives available, including national scholarship programs and programs fostering international exchange. Telemedicine networks have been implemented in Peru, Ecuador, and Colombia, but there have been no formal assessments of their effect on outcomes. Nongovernmental organizations have been active in attempts to raise public awareness of the disease, and governments have stepped up their efforts in cancer prevention and education.
Potential Actions to Improve Regional Cancer Control
Much is still left to be done, however. Mortality to incidence ratios in the region are improving but are still much lower than the corresponding statistics in higher-income countries. My colleagues and I summarized some of the potential actions that may be taken to improve cancer control in the Latin America and the Caribbean.
Alleviate fragmented health systems
Continuing fragmentation of health care systems and segregation between public and private sectors must be addressed to alleviate inequalities. Efforts toward universal health care must be increased, and the region must move beyond basic coverage and protection against catastrophic health expenditure for individuals with low incomes toward equitable services and coverage, including comprehensive care packages for all cancers.
Prioritize palliative care
Because palliative care is typically cost-effective, ambulatory palliative care should be prioritized, as it markedly enhances the quality of life of patients with cancer. Countries must develop, implement, and monitor national guidelines with clear recommendations on the end-of-life use of strong opioids to overcome the alarmingly low rates of use in Latin America and the Caribbean.
National cancer plans and cancer registries
The implementation and success of the numerous newly signed national cancer control plans have to be monitored. This process should be done in cooperation with international organizations including United Nations institutions and nongovernmental organizations. Existing cancer registries must increase their population coverage and the quality of data collected.
Financing cancer care
More support for public health care systems and universal coverage is needed. Countries should develop institutions (and strengthen existing ones) that can conduct region-appropriate health technology assessments, allowing for local cost-effectiveness thresholds to be assessed for drugs, screening, diagnostic, and therapeutic procedures.
Oncology and palliative care training
Nations must step up their efforts toward increasing the oncology workforce in order to further decrease the patient-to-oncologist gap. They should also extend actions to train personnel in screening, diagnosis, and care in remote areas.
Exchange programs within the region and with the United States, Europe, and Asia should continue to be used to improve patterns of practice and the establishment and adherence to regional-appropriate guidelines. Medical schools should improve palliative care training.
Disparities in cancer control
One of the priorities for cancer control in Latin America must be improving the quality of services and decreasing long wait times for diagnosis and treatment in disadvantaged settings, such as rural and remote regions and low-income urban settings.
World Health Organization (WHO)–endorsed programs of earlier diagnosis and timely treatment must be promoted, as these are more likely to be feasible and cost-effective than most screening programs currently available in higher-income countries.
The use of patient navigators and health workers belonging to indigenous and low-income communities can help overcome language, organizational, and financial barriers.
Cancer prevention and early detection
Although most Latin American countries have ratified the WHO Framework Convention on Tobacco Control, the implementation of tobacco control policies must be optimized and continuously evaluated, with particular attention paid to the high proportion of adolescent smokers and secondhand smoking in the region.
Strategies for cervical cancer screening and prevention must be adapted to local resource availability, and further regional studies are needed to identify and follow programs, including vaccination strategies. Timely access to the health care system for diagnostic workup and treatment are essential.
During the Brazilian Society of Clinical Oncology Annual Meeting, I stayed at a hotel within Iguazu National Park. One early morning, as the public gates were still closed and most of my co-guests were sleeping, I found myself alone walking the trails and contemplating nature. As I stopped and stayed motionless, life started to reveal itself. First came the insects we often see in cities: flies and mosquitoes. As I endured their presence, I was rewarded with more diversity: buzzing fireflies, multicolored mantises, and butterflies, wasps, and bees, of all colors and sizes, some as large as small birds.
There were plenty of birds as well: sparrows, toucans, parakeets, woodpeckers, and even a lone Caracara, a species of South American falcon. None of these are as interesting to me as the small and fearless southern lapwing I encountered in front of the hotel lawn on my way back. Originally from the Pampas grasslands region, this 30-cm tall, half-pound warrior is a proficient flyer, but it prefers to spend most of the time on land. Monogamous, usually mating for life, the “Quero-Quero” as it is known locally, lays eggs on the ground and fiercely defends its offspring. The national bird of Uruguay and state bird of Rio Grande do Sul, it has adapted well to urbanization and is often seen in parks and airports throughout the Southern Cone. If you’re ever watching a soccer match played in the region, you might be lucky enough to see a southern lapwing couple attacking players a hundred times their weight without so much as blinking an eye (matches have been stopped to relocate nests).
I wish we could be as fierce in our fight against cancer in low- and middle-income countries.
Photos of Iguazu Falls (top) and southern lapwing (bottom) courtesy of Dr. Lopes.