By Aakash Desai, MBBS, MPH, and Aju Mathew, MD, MPhil, FACP

Despite the tremendous progress made over the past few decades, the global cancer burden is estimated to be more than 29 million cases annually by 2040, causing 16.5 million cancer-related deaths.¹ The global rise in cancer burden will continue to disproportionately affect low- and middle-income countries (LMICs), where the number of cancer deaths occurring globally is projected to increase from 65% in 2012 to 75% by 2030.² In order to address this growing problem, we must strive to understand the unique challenges of oncology care in LMICs in comparison with high-income countries (HICs). In this review, we discuss seemingly contradictory, yet closely linked factors in global oncology which impede our progress in reducing cancer burden.

Traditional Medicine

Traditional medicine (TM) is a term that describes medical treatments (usually with no evidence of benefit) used instead of the conventional (mainstream) therapies. It has also been referred to as integrative, complementary, or alternative medicine (although definitions of these terms can somewhat vary). Some commonly used TM modalities range from oral supplements and dietary changes to spiritual treatments including faith healing, prayer, and traditional healers. TM often predates the evidence-based paradigm of conventional therapies and frequently represents indigenous cultural practices.

A systematic review reported that some of the reasons people give for turning to TM include curing cancer, improving the immune system, and treating adverse effects of conventional therapy. A high perceived effectiveness was found among most users of TM.³

We believe that this preference of TM impairs quality oncologic care and delays delivery of effective conventional therapeutics. A study of 4,872 patients with cancer in LMICs reported that 54.5% used TM for cancer treatment. Among study participants, only a median of 26.7% reported combining TM with conventional medicine, with the other half potentially receiving only TM for their cancer care.⁴

Anecdotally, the prevalence of TM use in HICs is lower, with most of its use occurring in combination with conventional therapies. Based on our experience, this phenomenon is possibly due to differences in litigation practices among LMICs and HICs (this article touches briefly on the matter⁵).

Cutting-Edge Care

When patients do seek conventional treatment, the availability and accessibility of oncologic care in LMICs poses another challenge. The landscape of conventional medicine (which is generally recognized to improve patient outcomes) is continuously changing with the advent of new therapies. Given the scarcity of resources in LMICs, oncologists frequently need to balance the cost of cancer care with patient outcomes. This becomes increasingly difficult as the cost of newer therapies skyrocket. Furthermore, with an increasing number of drugs approved via accelerated pathway⁶ and with the use of surrogate endpoints for these approvals,⁷ critical thinking and skeptical evaluation of these approval studies becomes essential for an oncologist in an LMIC.

One of the major roadblocks to critical appraisal of oncology literature in LMICs is inadvertently created by journals. First, the renowned journals which publish the trials that lead to U.S. Food and Drug Administration (FDA) drug approvals charge a significant fee (in dollars) for subscription or even single-article access. Hence, for a typical oncologist practicing in LMIC, the only data available for critical review are the abstracts, which are often inadequate. This prevents any self-assessment and appraisal of literature causing overreliance on FDA approvals for treatment-related decisions, which serve as the “final word” on efficacy of these treatments.

Second, authors (mostly, medical writers) have mastered the art of subterfuge—they gloss over the negatives and highlight marginal gains as revolutionary progress. For example, a marginal improvement in progression-free survival (PFS) may be touted as a “scientific breakthrough” and “game changer for patients” despite not improving any meaningful outcomes for the patients and their families.

Most of the FDA-approved drugs undergo price regulation in the United States market due to involvement of third-party payees (such as insurance companies), who require evidence justification to support clinical use of therapies. The major threat to applicability of this model in LMICs is a fee-for-service structure and a lack of third-party payee. This shifts the power dynamic in the decision making to the physician. Thus, the reliance on FDA drug approvals, paywall issues, fee-for-service payment structure, and the lack of third-party regulation all complicate oncology care in LMICs.

In conclusion, socioeconomic disparities prevalent among the LMICs, amplified by lack of universal health care, lead to inadequate access to quality health care for large populations of people living in these low-resource areas. On one hand, there are significant barriers to getting access to curative treatment and quality surgical services like lumpectomy and sentinel node assessments. On the other hand, for the affluent sections of the society, despite the access to newer therapies, the unjustified use and lack of regulation impacts the cost factor in the value-based health care equation. Finally, the lack of access to conventional medicine may feed the reliance and increased utilization of traditional medicine, adding fuel to the fire.  

As we understand that these seemingly contrary forces are indeed complementary, we must strive to bring equity, awareness, regulation and transparency to provide value-based health care in LMICs.

Dr. Desai is currently an Internal medicine resident in the Department of Medicine at the University of Connecticut Health Center. He will be pursuing his hematology/oncology fellowship at Mayo Clinic Rochester starting in July 2020. He holds a master’s degree in public health from the University of Texas Health Science Center in Houston and a certification in Health Professions Education. He serves as a vice chair of the Connecticut State Medical Society Resident and Fellow Section. Follow him on Twitter @ADesaiMD.

Dr. Mathew is an oncologist in Ernakulam Medical Centre and MOSC Medical College in Kerala state in India. His research focuses on global oncology, supportive care, breast cancer, and gastrointestinal malignancies. Follow him on Twitter @ajumathew_.

References

1. International Agency for Research on Cancer, World Health Organization. Cancer Tomorrow. 2020.
2. Shah SC, Kayamba V, Peek Jr RM, et al. Cancer control in low-and middle-income countries: is it time to consider screening? J Glob Oncol. 2019;5:1-8.
3. Diorio C, Lam CG, Ladas EJ, et al. Global use of traditional and complementary medicine in childhood cancer: A systematic review. J Glob Oncol. 2017;3:791-800.
4. Hill J, Mills C, Li Q, et al. Prevalence of traditional, complementary, and alternative medicine use by cancer patients in low income and lower-middle income countries. Glob Public Health. 20190;14:418-30.
5. Cloatre E. Law and biomedicine and the making of ‘genuine’ traditional medicines in global health. Critical Public Health. 2019;29:424-34.
6. Gyawali B, Hey SP, and Kesselheim AS. Assessment of the clinical benefit of cancer drugs receiving accelerated approval. JAMA Intern Med. 2019;179:906-13.
7. Kim C, Prasad V. Cancer drugs approved on the basis of a surrogate end point and subsequent overall survival: an analysis of 5 years of US Food and Drug Administration approvals. JAMA Intern Med. 2015;175:1992-4.