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____ Thursday October 29 , 2015 ____


Cancer Care

Commission shows good progress in cancer care in Latin America, but major obstacles remain

Boston, MA - Following the success of the 2013 Lancet Oncology Commission on cancer care in Latin America [1], The Lancet Oncology today launches a second Commission on cancer in this region, highlighting the promising progress that has been made in just 2 years, but also the substantial barriers that remain to ensure all those that need cancer treatment and care receive optimal clinical management.

Overall cancer mortality in Latin American Countries is about twice that of more developed high-income countries, and ageing of the Latin American population, which will lead to more than 100 million people over 60 years by 2020 (roughly a sixth of the total population), will continue to increase cancer incidence in this region. About half of all cancers in Latin America are caused by smoke (tobacco and indoor cooking/heating) and infections, so it is imperative to urgently address these issues.

Since the 2013 Commission, the authors have identified a number of improvements in cancer care in Latin America, either specifically related to cancer or to general healthcare initiatives that will also benefit cancer patients, such as:

· The proportion of people affiliated to any kind of health insurance programme grew from 46% to 60% between 2008 and 2013.

· For 2014, WHO reported an 8% increase in the number of countries (60% of the whole region) with a National Cancer Plan, with the following countries having newly adopted plans: Suriname, Ecuador, Dominican Republic, Trinidad and Tobago, Puerto Rico, Peru, El Salvador, and Colombia.

· Latin America, and most notably Brazil and Argentina, has begun to address the shortage of cancer specialists. Brazil has shown an increase of 77% in oncologists since 2011 (from 1457 to 2577). Concurrently, the number of haematologists has also increased by 40% (from 1420 in 2011 to 1985 in 2015), and that of radiotherapists by 12% (from 444 in 2011 to 497 in 2015). These rises are in the context of an 11% increase in cancer cases in Brazil (from 518 000 new cases in 2012 to 576 000 in 2014).

· Since the previous Commission and as of 2014, 20 countries in the Latin American region have introduced human papillomavirus (HPV) vaccination and now include it in their national recommendations to prevent cervical cancer. By the end of 2014, Brazil alone was estimated to have given at least one dose (still sub-optimal) of the vaccine to more than 5 million girls between the ages of 11-13.

· Many countries across Latin America have signed up to the Global Action Plan for the Prevention and Control of Non-Communicable Diseases 2013–2020, endorsed by WHO, which aims to achieve a 25% reduction in premature mortality from non-communicable diseases (including cancer) by 2025.

· In 2013, WHO and the Pan-American Health Organization (PAHO)[2] launched the Women’s Cancer Initiative to bring together partners to set up action for the prevention and control of cervical and breast cancer in Latin America.

· The Colombian Ministry of Health and Social Protection has expanded its social insurance programme to cover all types of cancer.

· Since January 2014, the administration of chemotherapy and radiation treatments is free of charge in Uruguay.

· The Atlas of Palliative Care was published in Latin America, which found a growth of more than 400% the number of palliative services since 2006.

However, the authors say that despite this progress, major changes are needed in many areas to increase the standard of cancer treatment and care in Latin America. The following areas of concern have been identified:

· Compared with high income countries, Latin America in 2015 remains far behind in terms of public expenditure on health and cancer care. Argentina and Mexico spend around 6% of gross national product (GNP) on health care, compared to 9% for the UK, 11% for Germany and 17% for the USA, which reflects a large gap between Latin American and high-income countries not only proportionately but also in terms of absolute dollars. Only Brazil, at 9%, is close to the proportion spent in high-income countries.

· In Latin America, only Brazil, Cuba, Costa Rica, and Uruguay can be deemed to be countries with integration of social security and public insurance, and only Brazil, Cuba, and Costa Rica can be judged to have universal health care.

· Many countries still have no specific training in palliative care (including Bolivia, El Salvador, Honduras, and Nicaragua). Additionally, data from 2002 showed that Latin America accounted for less than 1% of the world’s opioid drug consumption for pain relief. Consumption of strong opioids still lacks behind developed countries today with no Latin American country exceeding 15 mg/capita per year.

· Under-implementation of new technologies has not improved substantially since the previous Lancet Oncology Commission in 2013 (apart from few exceptions, such as PET scanning technology improvements in Uruguay).

· Pharmaceutical trials for expensive new anti-cancer therapies are largely unhelpful to most patients in Latin America. Patients participating in trials of expensive new anti-cancer therapies sometimes cannot complete treatment once their trial ends, and the trials often do not lead to approval in these regions.

· There are often geographical disparities where most cancer specialists are located in major hospitals in big cities, requiring patients from rural and remote areas to travel far distances to these hospitals for cancer care. In addition, waiting times in these centres can be unacceptably long with reports from Mexico and Brazil describing median waiting times of 7 months or more for patients with breast cancer from symptomatic presentation to initial treatment.

· The quality of cytological screening for cervical cancer varies widely across the region, so more education and training of medical personnel is essential.

· Despite the recent decline in smoking rates, the proportion of people who smoke is still high in Latin America. Alarmingly, in some countries the proportion of adolescent or young adult smokers is even higher than the proportion of adult smokers (for example, in 2010, 48% of young adults aged 15–24 years in Chile were smokers, versus 33% of adults).

· Only 46% of the population in the PAHO region, which includes the USA and Canada, have protection against exposure to tobacco smoke in indoor public places and at work and only 26% of the PAHO population are protected against tobacco advertisement and promotion. While all countries in Latin America have ratified the Framework Convention on Tobacco Control, most countries still do not have adequate implementation of tobacco control policies.

· Wood-smoke exposure from stoves has been specifically linked to EGFR-mutated lung cancer within the Latin American region. This association, which is being investigated from an epidemiological perspective at centres in the USA, Bolivia, Mexico, Peru, and Venezuela, would explain the high-rates of EGFR-mutated lung cancer in the region.

· Better cancer registries are desperately needed in all Latin American countries to more accurately quantify the cancer burden in the region and the resources required to combat it.

The authors say: “To provide accessible, high quality cancer care, Latin American countries need to continue to work towards achieving true universal health care, which means equitable services and coverage for all patients. To achieve this goal, financial and political challenges must be overcome, and inefficient practices must be eliminated.”

They add: “We have been surprised and gratified that so much progress has been made in only 2 years. Latin American states, some more than others, are in turmoil related to funding, organisation, and execution of cancer programmes. Nevertheless, what is widely evident in Latin America are the steps towards the restructuring of health-care systems, progress on development of cancer registries, adjustments to funding towards universal health care and support of the underserved, and initiation of programmes for primary cancer prevention.”

They conclude: “We hope that future updates we undertake will show even greater alleviation of the overall cancer burden in Latin America.”

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